A common inquiry we receive from patients is what to do if their insurance company has denied their claim related to their cancer treatments. One service we often direct individuals to is the OmbudService for Life and Health Insurance (OLHI). But who are they? And how can they help you?
We asked and they answered.
Who is OLHI and how do you help patients?
The OmbudService for Life and Health Insurance (OLHI) is a free, bilingual, independent, and impartial alternative dispute resolution (ADR) public service for Canadian life and health insurance consumers. As an ADR public service, OLHI provides accurate and accessible information about life and health insurance concerns. This includes guiding consumers through the complaints process, answering their questions, and helping them find lost policies or policies of deceased loved ones.
Does OLHI have specific relationships or partnerships with insurance companies?
In Canada and around the world, regulators and OmbudServices in the financial services sector are typically funded by the industries they cover, as opposed to the general taxpayer. Life and health insurance companies are required by law to support an impartial dispute resolution service. OLHI’s independence is safeguarded by ensuring that the insurance companies do not control our operations. Our operations are overseen by the Canadian Council of Insurance Regulators and our independent Board of Directors.
What kind of complaints do you review?
OLHI can review a complaint about a life or health insurance claim after a consumer has received a final position letter from their insurance company. This includes, but is not limited to, complaints about group benefits, dental and health, drug coverage, individual insurance, life insurance, extended health, and disability insurance.
When can a patient struggling with an insurance claim come to you for help?
OLHI can review a complaint about a denied claim if you have gone through your insurer’s internal process. We’ll know that you completed this process if you have a “final position letter”—it’s one of the first things we’ll ask for after you submit a complaint to OLHI.
You can also visit our website for more information about the complaints process and how to contact your insurer's complaints office.
Does it cost money for a patient to use your services?
Our services are completely free.
What is a final position letter?
A Final Position Letter is a written decision made by the insurer that outlines its final position about a consumer claim. You can read more about it here.
What is the process for submitting a complaint to OLHI?
Step 1 – Get a Final Position Letter: All insurance companies have an internal complaints process. You must try to resolve your complaint directly with your insurance company and get a Final Position Letter from them. Once you have received a Final Position Letter, you can submit your complaint to us.
Step 2 – OLHI confirms we can review your complaint: If you have a Final Position Letter, we will contact you to gather more information and to get your written authorization to review your complaint.
Step 3 – OLHI reviews your complaint: If you have received a Final Position Letter, and your complaint is reviewable then an OLHI Complaints Analyst will start a review. The Complaints Analyst will look at all the information you and your insurance company provided, including your insurance policy. We may come back to you and your insurance company to request more information. If we believe your complaint has merit, it goes to an OmbudService Officer (OSO).
Step 4 – OLHI investigates your complaint: If the OSO agrees there is merit to your complaint, OLHI will make a non-binding settlement recommendation to your insurer. During an investigation, the OSO may also ask you or your insurance company for more information.
Step 5 – Senior Adjudicative Officer Investigation: If your insurance company doesn’t accept our recommendation, OLHI’s Senior Adjudicative Officer may investigate the complaint and try to negotiate a settlement with the company.
How long can the process take?
We make every effort to review the complaint and conclude the treatment of such within 120 days upon receipt.
Are there cases you do not take on?
OLHI cannot review some types of complaints, including:
- Complaints that aren’t about life or health insurance.
- Complaints about independent insurance advisors.
- Complaints about foreign life and health insurance.
- Complaints that are already underway in court, in a tribunal or with a mediator.
- Complaints that have already been decided by a court, tribunal or mediator.
- Complaints made by a business.
- Complaints from medical practitioners or professional services providers to collect payment from a life and health insurance company.
- Complaints related to an employee benefit plan the insurance company is only administering on behalf of the employer (known as an administrative services only plan).
We may also decline a complaint under these circumstances:
- The complaint is currently under investigation by a regulator.
- There is a more appropriate venue to address the complaint.
- Too many years passed before the complaint was submitted to OLHI.
Does submitting a complaint with OLHI guarantee a result?
OLHI provides an impartial, free service to Canadian life and health insurance consumers. We do not advocate for consumers or insurers. Our Analysts will do a thorough job in reviewing the file, including documents sent by consumer and insurer. Every case is unique, and our Analysts review each one in a non-partisan way. If OLHI finds that your claim has merit, we can ask your insurance company to reconsider a decision. Sometimes, this can result in a negotiated settlement agreeable to both sides.
If a person is not satisfied with the result, are they required to take it?
If we find your complaint does not have merit or we are unable to settle the complaint, you have the right to pursue other remedies, such as legal action or a complaint to a local regulator.
Can a person come to OLHI for general questions about insurance?
Our website offers general information about life and health insurance. We offer a find insurance search tool for those looking to purchase coverage from an insurance company, but we don't sell insurance. Also note that we are not linked to your insurer’s internal database and have no direct connection with their staff. OLHI is an external, non-profit organization. Questions related to your specific policy need to be addressed to your insurer.
For more information about OLHI’s complaint process and how to get in touch, visit https://olhi.ca/complaints/.